Anecdotal observations by Dr John Flynn, Director, Cosmedic & Skin Clinic, Gold Coast.
Introduction
Hyaluronic acid fillers are one of the most commonly utilised cosmetic procedures, with the numbers exceeding hundreds of thousands of injections every year. It is not too surprising then that reactions to this seemingly innocuous product occur from time to time.
In trying to solve filler reaction issues, the most important and helpful item is a careful history.
Let’s look at a real case and see how it unfolds…
The patient
Female, early 30s, long history of HA fillers and neuromuscular toxins, of different brands.
No allergies reported, general health good, socio-economically stable.
Medication: Escitalopram 10mg daily for anxiety and mild depression symptoms.
Presentation
The patient presented with a history of having had filler injection into her lips 7 days previously.
At 48 hours post-injection, her lips became red, swollen and tender. Although the patient had a history of HSV infections, there were no vesicles noted. She did not know the particular brand of filler, nor the quantity used. She thinks it might have been one or two syringes. She paid “a bit over $900”.
She had been commenced on Cephalexin oral antibiotic 500mg qid. The symptoms had not improved over the next 24 hours and so she returned to the injector clinic. Hyalase 5.0ml was administered. No effect was observed, and so a further 3.0mls of Hyalase was injected 4 hours later. Still there was no improvement and so the patient presented to the ED of the local hospital. She was admitted and treated with IV Flucloxacillin for 3 days. Her treating physician in hospital advised the patient that “it was not an infection”. His view was that it was “an allergic reaction”.
The patient then attended my practice, without a discharge summary, and without any pathology results. She reported there were no swabs taken for culture because there was no discharge or “fluid” associated with the swollen lips. She had no other obviously infected sites such as sinusitis or dental cavities or gum disease.
Examination showed a healthy looking, slightly stressed young lady with mildly swollen lips not too dissimilar to what is often observed in patients a few days after a filler injection. So, not much to see right now.
Filling in the gaps
So, what to make of this story? There are a few gaps in the history so far and no clear diagnosis.
Certainly, there is no supportive information and not much of note to see in her presentation. All we have is the history. Let’s see if we can break it down.
Swelling and pain onset at 48 hours. This timeframe might fit with either a bacterial or viral infection. Equally, it may fit with a type of allergic reaction. The symmetrical nature of the swelling she described and the fact it is in both lips with the absence of vesicles, makes it less likely that the condition is HSV. Bacterial infection is still a possibility. But, the description of the swelling being even, in all areas injected, fits more with an allergic reaction of some type. Does the time frame fit with an allergic reaction? Maybe! Does the fact that she has a history of use of a variety of HA fillers without previous incident rule out an allergic reaction? Certainly not!
Was it a good decision to start antibiotics? Well, Cephalexin as an antibiotic is a fair choice, and the dose is appropriate, but was it needed at all?
Changing course after only 24 hours?; is that enough time to allow the antibiotic to work? There is no history that she was getting worse, just not improving.
Delayed commencement of Hyalase. Hyalase was a good choice if one considers the “reaction” diagnosis. Unfortunately, its use has been delayed by the choice to commence with antibiotics. We don’t know, however, how much Hyalase was used. We are told it was 5ml, but this does not give us how many units were in that 5ml. Hyalase is presented as an ampoule of 1500 units of a dry powder. The ampoule itself has a volume of 1ml. Was one 1500 unit ampoule made up into 5.0mls or were 5, one ml (1500 unit) ampoules used, meaning 7500 units? The lack of specificity does not help us at all.
With no obvious response after 4 hours, a further dose of 3ml Hyalase was given. Again, we don’t know how many units were used.
How many units are enough? How long should we wait before we give a further dose? What are the actions and potential adverse reactions to Hyalase? Do you have a protocol in your practice?
Later that same day, she presented to the ED and was started on the IV Flucloxacillin for the next 3 days. Three days of IV antibiotics is a substantial treatment regime. We don’t know why the hospital physician determined that “it was not an infection” and we don’t know what other medication was administered to convince him it was “an allergic reaction”. Did she have any antihistamine or any steroids?
So, presented with this history and the apparently “cured” patient, what do we do now? She would like to continue with her “filler career”.
There seems no doubt that she sustained a significant event, but the history has a number of substantial gaps, and we cannot be certain of the diagnosis. There is missing information from the original injector clinic, missing information from the ED. The patient herself is not the best historian; she does not recall either the brand or the amount of the filler product. She does not want to identify the injector clinic because she “does not want any trouble”. Really, quite amazing, and despite prompting to allow us to fill at least some gaps in the story, no information is forthcoming.
Perhaps we might be suspicious that she injected herself. Maybe? Did she use an unregistered product? Maybe?
The ED department will send a discharge summary “in due course” and “privacy considerations are important and must be respected” and since she did not nominate a GP when she attended then “things may take time”.
So, what did we do?
Over the next several weeks she was given 0.1ml test doses of three different brands of commonly used HA filler into her inner arm. None elicited any adverse response. She was given a card with the names of the fillers tested to carry with her for future reference. Recent contact with the patient has indicated she has had a number of episodes of filler since this time without adverse events. So, in the end, we still don’t know what caused the presenting problem. AMP
